| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,700 |
3,629 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
6,729 |
6,590 |
$110K |
| D1120 |
Prophylaxis - child |
2,950 |
2,874 |
$73K |
| D1206 |
Topical application of fluoride varnish |
3,592 |
3,520 |
$54K |
| D0274 |
Bitewings - four radiographic images |
893 |
876 |
$20K |
| D2740 |
Crown - porcelain/ceramic |
33 |
14 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
225 |
109 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,012 |
961 |
$9K |
| D0272 |
Bitewings - two radiographic images |
239 |
234 |
$4K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$2K |
| D1351 |
Sealant - per tooth |
79 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$470.80 |
| D1999 |
|
47 |
45 |
$0.00 |